Medical Record Review

Reviewing medical records is a staple skill of the practicing medical expert. In nearly every case in which forensic psychiatrists are involved in providing opinions, a careful review of the available medical records augments the face-to-face diagnostic clinical evaluation, testing, and additional collateral information. These elements are combined and considered together, in sum, to arrive at the ultimate opinion of the medical expert witness. There are even some cases, such as in medical malpractice, where the medical record review serves as the primary basis for the opinion generated and face-to-face evaluations are rarely conducted.

In addition to these standard roles for medical record review and that of a medical expert witness, attorneys, organizations, or individuals may periodically find it useful to have guidance in interpreting mental health records, psychiatric literature, or other documents to clarify strategic decision-making as it relates to a legal matter. There may be situations where there is evidence of an extensive history of mental illness, but the meaning of the history, and in particular as it applies to a specific legal context, can be difficult for the lay person to discern. We consider one of the principle roles of the forensic psychiatrist to be that of an educator, where the ability to apply context and explain the meaning and impact of symptoms on rational thinking and behavior helps those involved in a legal case to arrive at a more informed and balanced view of the individual and circumstances in question.

At Rocky Mountain Forensic Psychiatry, we are available to provide brief or comprehensive medical record reviews to assist attorneys in working through cases as well as serve as the medical expert witness, or to help individuals interpret documents in a manner that helps to provide meaning and context. For more information, please contact us.